• Primary goal: Removal of excess skin, orbicularis muscle, and fat
• Secondary goals: May be combined with adjunctive procedures described in subsequent chapters, particularly lateral canthal reinforcement and SOOF lift.
• Special anatomy: None
• Anesthesia: Local anesthesia with oral or intravenous sedation
• Operative technique: The skin is incised just below the eyelid margin along its full length and slightly beyond into the lateral canthus. The exposed orbicularis muscle is incised along its length in a similar fashion. A skin-muscle "flap" is lifted off of the underlying orbital septum using blunt dissection with cotton-tipped applicators and sharp dissection with scissors. The skin-muscle flap dissection extends downward over the entire lower eyelid to a level approximately even with the orbital bony rim. The orbital septum is incised to expose the three fat pockets of the lower eyelid. Excess fat is teased free and clamped. The fat is removed with scissors, and each "stump" is cauterized before allowing it to retract back into the orbit. The patient is asked to open his or her mouth and look upward towards the forehead while the surgeon drapes the skin-muscle flap over the initial incision to determine the amount of "extra" tissue (generally, only a small amount). Any excess tissue is trimmed. The skin edges are closed using sutures.
Step-by-step photos
• Variations: Many variations have been suggested, most of which have to do with placement of incisions or level of penetration from one tissue layer to the next. While all such adaptations are attempts to overcome the basic insufficiency of this operation (extensive internal disruption of the eyelid, which is, in effect, filleted), none, in our opinion, make any sort of startling difference. If the orbicularis muscle is "hypertrophic" (and bunches into a "roll" just below the lashes when smiling), a thin strip of extra muscle may be removed (surgery photos). In patients with markedly excessive skin, only a skin flap may be dissected (rather than skin-muscle), and the orbicularis muscle then entered lower down near the bone (which allows for more skin relative to muscle to be removed when the flap is trimmed).
• Advantages (theoretical): In addition to fat removal or repositioning, excess skin and orbicularis muscle may be removed (which is not possible in "pure" transconjunctival blepharoplasty). In most patients, however, skin/muscle removal in the lower eyelid is not indicated and adds significant risk of eyelid contour distortion.
• Limitations: There are many problems with this operation, as discussed below and in Chapter 30: Lower Blepharoplasty Complications. Its "fatal" flaw is its highly invasive nature, wide dissection, and extensive violation of the orbital septum (see Chapter 4: Eyelid Anatomy) that create an undesirable sheet of scar tissue inside of the lid and may hinder normal lid movement and almost always alter the shape of the eyelid opening. Furthermore, redraping or removing skin does not improve skin quality (wrinkling) but commonly results in rounding of the lateral canthal angle and vertical inadequacy of the eyelid skin. Accompanied by so-called "reinforcement" procedures at the lateral canthus (canthopexy), this operation has remained popular with some practitioners.
• Care and recovery: As noted in Section Four
• Risks and complications: As in Chapter 28: Eyelid Surgery Risks and Complications. The risk of eyelid malposition (retraction, ectropion) following lower blepharoplasty undertaken from a skin approach is substantial, while the similar risk with transconjunctival eyelid surgery is minimal. More bruising, more swelling, and slower healing are to be expected. Uncommonly, eyelashes may be lost.
• Comments: "Pure" transcutaneous lower blepharoplasty (that is, without adjunctive procedures such as lateral canthal reinforcement or midface resuspension) has been called a "discredited" operation and has, in our opinion, seen its day. Even when well-performed and accompanied by canthopexy, the procedure frequently results in an unnatural "surgical look". If complicated by lid retraction, the abnormal exposure and poor closure can cause major eye problems for those with ocular disease, contact lenses, or LASIK as well as substantial disfigurement. We disagree that canthopexy is protective over the long-term and have not offered the trancutaneous approach to lower lid fat removal for over a decade.
• Advantages of Transcutaneous Lower Blepharoplasty
• Disadvantages of Transcutaneous Lower Blepharoplasty
